Can structural change help tackle health inequality?

If there is one constant and seemingly intractable health challenge in Scotland it is health inequality. The Joseph Rowntree Foundation’s, Monitoring poverty and social exclusion in Scotland 2013’, is the latest of a number of reports that draw attention to this issue.  The health section highlights three main points:

• Health inequalities in Scotland are not only stark but growing. A boy born in the poorest tenth of areas can expect to live 14 years less than one born in the least deprived tenth. For girls, the difference is eight years.
• Rates of mortality for heart disease (100 per 100,000 people aged under 75) are twice as high in deprived areas as the Scottish average.
• Cancer mortality rates in the poorest areas (200 per 100,000) are 50% higher than average, and have not fallen in the last decade, while the average has fallen by one-sixth.

The latest ‘Long-term Monitoring of Health Inequalities: Headline Indicators’ report also shows that healthy life expectancy among men in the poorest areas of the country is just 47. The Glasgow Centre for Population and Health provides a summary of Scotland’s mortality position relative to other mainly Western European countries. Sadly, it would appear that Scotland is "Still the sick man of Europe" - but women are getting sicker too. Finally, Sir Harry Burns explained to the Holyrood Public Audit Committee that health inequality is biggest issue facing the country.

The Scottish Government has established a Ministerial Taskforce on Health Inequalities to examine all available evidence and to suggest new or improved ways to reduce the difference in life expectancy and health among the whole population. Audit Scotland has suggested that resources to be shifted from more affluent areas to poorer ones to tackle persistent health inequalities. Scottish Labour Leader, Johann Lamont MSP has also opened a debate about spending on some universal services.

I spent some six months last year as an expert advisor to the Christie Commission and tackling inequality is a theme that runs throughout that report. While reducing inequality is a much bigger issue than reorganising public services, the Commission highlighted preventative spending and breaking down service silos as approaches that could make a difference. In a less publicised section, the report points to plans in the islands to create all purpose authorities by merging health boards and councils.

There is an element of this approach in the Scottish Government’s health and care integration plans. Although instead of merging services, the favoured model is a sort of local quango made up largely of health board and council representatives. They have recently published the consultation response and there is significant criticism of this approach, not least on grounds of democratic accountability. This is an issue taken up at the recent CoSLA conference, reflecting concerns over growing centralisation of public services. The Christie Commission in their tests for structural reform also cautioned against centralisation.

The role of local government in tackling health inequalities has perhaps been forgotten in recent years. The new guide for councillors published by CoSLA and NHS Scotland is therefore a welcome initiative. The guide’s key suggestions for action to address health inequalities include providing services universally, but with scale and intensity that are proportionate to the level of disadvantage. While offering intensive support, it cautions against targeting geographical areas defined as deprived because this means missing the vulnerable who live elsewhere. Particularly rural areas that have people experiencing inequalities that may be harder to identify. The guide also reinforces the Christie recommendation that local agencies work together with common aims and measures to reduce health inequalities.

However, barriers remain to better joint working. I highlighted a number of these in evidence to the Holyrood Local Government Committee recently. The top down service design model is still prevalent, instead of engaging with staff and service users as Christie recommended. There is too much emphasis on contractual procurement that has resulted in a race to the bottom in care service quality. And there is a need for a broad staffing framework to enable flexible working between staff from different agencies.

Another approach is to return to the Christie nod in the direction of all purpose authorities. Merging councils and health boards would structurally join up services and ensure they were democratically accountable and a bulwark against centralisation. As Christie again recognised, our councils are the largest in Europe and no one on the continent would regard our councils as ‘local’. The Liberal Democrat’s constitutional change proposals recommend the creation of Burgh councils to run truly local services. However, no one is seriously suggesting that even most of our current councils are large enough to run acute services. So we are really talking about merging community health with other council services, including social care.

One country that already does this is Norway. They have small local councils based on natural communities that provide most local services, including community health and care provision. They also have regional councils for strategic functions. I was discussing this with a trade union delegation from Norway only a few weeks ago and they agreed that this does provide joined up and democratically accountable services. However, they also pointed out that integration between primary and acute health services did not operate well under this model. This could be a problem in Scotland as one of the biggest challenges is shifting resources from acute to community, by reducing unplanned admissions to hospitals.

In essence it appears that wherever you draw the organisational line integration is challenged. This is particularly the case when staff operate in a silo mentality and services are fragmented through marketisation. The Welsh Government is developing a ‘One Wales’ approach that seeks to break down these barriers, but this is more difficult in a country the size of Scotland. We could however develop a one public service approach, as Christie suggested, that creates common statutory duties, staff training, total place budgeting and reduces other barriers to joint working. It may well be that this approach delivers better long term results than structural change.


This piece also appears in the April 2013 edition of Healthier Scotland.